SCP Vaccination Consent Form

Name (First and Last)*
Date of Birth*

MonthDayYear
MaleFemale
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
Format: (000) 000-0000.
Email (For appointment reminders)
example@example.com
yesno
Chatham Central High SchoolChatham CharterChatham Middle SchoolJordan-Matthews High ScoolNorthwood High SchoolSeaforth High SchoolSiler City ElementarySilk Hope ElementaryVirginia Cross ElementaryCentral Services
Allergies
Race*
Primary Care Physician*
Influenza (Flu)Influenza High-Dose (patients over 65 are eligible to receive)Influenza Adjuvanted (65+)Shingles (Shingrix)Hepatitis B (Age 20+)RSVCOVID-19Tetanus, Diptheria (Td)Tetanus, Diptheria, Pertussis (Whooping Cough) (TDap)PneumoniaOther
Please upload a photo of the front and back of your insurance card. If unable to do so, please bring your insurance card with you to receive your vaccine.

Cancelof

Screening Questionnaire*

Rows	Yes	No
1. Are you feeling sick today?
2. Do you have any allergies to medications, foods (i.e. eggs), latex, or a vaccine component (i.e. gelatin, neomycin, polymyxin, yeast, thimerosal, etc.)?
3. Have you ever had a serious reaction (including fainting) after receiving a vaccination?
4. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (i.e. Diabetes), anemia, or other blood disorder?
5. Do you have cancer, leukemia, HIV/AIDs, or any other immune system problem? Have you been diagnosed with Rheumatoid arthritis, ankylosing spondylitis, or Crohn's Disease?
6. In the past 3 months have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
7. Have you had a seizure, or a brain or nervous system problem, or Guillain-Barre?
8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
9. For women, are you pregnant or is there a chance you could become pregnant during the next month?
10. Has any physician or other health care professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician's office or hospital?
11. Have you received any other vaccines in the last 4 weeks?
12. Do you have an open wound, puncture, or tissue tear that prompted you to get a tetanus shot?
13. For COVID only, have you had COVID-19 in the past 3 months or have a history of myocarditis?

Appointment
Consent: I have read, or have had read to me, the written information regarding the vaccines(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information my Sheet. I, on behalf myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Siler City Pharmacy LLC, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administation of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Siler City Pharmacy LLC to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
At this time we are not requiring appointments to be made. Once this form is completed, you may come to the pharmacy anytime between 9:30AM-5:30PM Monday through Friday or 9:30AM-2:30PM on Saturdays.
Signature*
Name (print)*
I am parent/legal guardian
Date*

MonthDayYear
Date
Should be Empty: